Several victims of trafficking for domestic servitude report being forced to eat and sleep on the floor, being told they should live “like an animal” and only being permitted to eat leftovers when onerous tasks had been completed and the other children of the house had already eaten. Some describe the repeated threat of being locked outside the house in all weathers, and of this threat being carried out. People who have been exploited in all forms of forced labour become conditioned to taking orders, feeling afraid, working for very long hours on very little sleep and having to focus on the task in hand rather than on themselves and their own needs. They may be deprived of any private space or freedom of movement. Even their basic functioning, for example going to the toilet, controlling their menstruation (while held in sexual exploitation), eating and drinking, personal presentation and responses to their own illnesses or injuries may be controlled by traffickers. In all such cases autonomy, sense and validity of “self ” is violated. All professionals who work with victims of trafficking need to understand issues of low self-esteem, self-blame and shame, and bear in mind the difficulty that any person would have in describing, and coping with, these kinds of experiences. A South East Asian man trafficked for forced labour Thanh is suffering from severe sleep disturbances and feels embarrassed and ashamed of waking in the middle of the night with nightmares. An Eastern European woman trafficked for sexual exploitation Emily says she feels guilty for trusting the trafficker who promised her a good job in the UK and she blames herself for all that has happened to her as a result. She also feels bad because, if she had been born a boy, this would not have happened and she would have been able to look after her family instead of letting them down. Clinical notes on a West African woman trafficked for sexual exploitation Valerie is affected by her physical scars because they remind her of her past in forced prostitution. They affect her socially because she is reluctant to undress in front of other women, for example her female friends, or in a communal changing room, since she does not want others to see and enquire about them. She deliberately chooses clothes with a high neckline in order to cover them. 5.6 The Psychological Effects of Rape and Sexual Abuse Rape is sexual torture. The Istanbul Protocol states that “Sexual torture begins with forced nudity … . An individual is never as vulnerable as when naked and helpless. Nudity enhances the psychological terror of every aspect of torture, as there is always the background of potential abuse, rape or sodomy. Furthermore, verbal sexual threats, abuse and mocking are also part of sexual torture, as they enhance the humiliation and its degrading aspects”. 59 The rape and sexual abuse of victims held in sexual exploitation devastates their self-esteem,60 demeaning and degrading them. It violates their right to autonomy over their own bodies, instilling the perverse and frightening reality that their body is “owned” by others and for sale in a transaction that takes place without their presence or consent. The psychological effects of rape that have been observed in victims of trafficking at HBF include: – Post-Traumatic Stress Disorder (PTSD) – Depression. This often co-exists with PTSD and is characterized by persistent low mood and/or loss of interest in most activities and reduction in the capacity to enjoy them, together with other features such as disturbance of sleep and appetite. A sense of reduced self-worth is particularly common. Both depression and PTSD may be associated with suicidal acts which may lead to acts of self-harm and/or attempted suicide. – Feelings of having been defiled. – Fear of men. Victims may avoid any contact with men or certain types of men who are similar to their traffickers or their associates (defined for example by skin colour, age or body size) whom they perceive to be a danger to them. – Fear of being in any situation where the victim is not in control of their own environment/security. – Difficulties trusting others and forging positive relationships with others. – Difficulties disclosing their past to others, even those with whom they have a close relationship. In British Medical Journal, 79